Mindful Leadership in Technical Safety - WordPress.com · Duration: at least two minutes - 30 seconds brushing each • •

Health and Safety Executive

© Crown Copyright, HSE 2016 HSL: HSE’s Health and Safety Laboratory

Mindful Leadership in Technical Safety

Rosemary Whitbread

HSL: HSE’s Health and Safety Laboratory © Crown Copyright, HSE 2016 © Crown Copyright, HSE 2016

Developing collective mindfulness

HSL: HSE’s Health and Safety Laboratory © Crown Copyright, HSE 2016

“A company whose employees were all individually

mindful of risks would be a dream come true for

many employers. Mindfulness at the individual level

is arguably the ultimate goal. But …individuals will

only be mindful if there are processes of

mindfulness at the organisational level.”

(Hopkins, 2002)

Developing collective mindfulness


Safety Culture

• What is safety culture?

• Why should/do organisations care about it?


A three aspect approach to safety culture

Safety Culture “The product of individual and group values, attitudes, perceptions, competencies and

patterns of behaviour that can determine the commitment to, and the style and

proficiency of an organisation’s health and safety management system”.

ACSNI Human Factors Study Group, HSC (1993)

(Based upon Cooper 2000, HSE RR 367)

Psychological Aspects

‘How people feel’ Can be described as the

‘safety climate’ of the

organisation, which is

concerned with individual

and group values, attitudes

and perceptions.

Behavioural

Aspects

‘What people do’ Safety-related

actions and

behaviours

Situational Aspects

‘What the organisation

has’ Policies, procedures,

regulation,

organisational structures,

and the management

systems


ASCENT: A framework for safety culture excellence

Focus groups

Interventions

SMART action plans

Intervention impact

evaluation

Senior management commitment

Project plan

Steering group

Communication strategy Foundation

Focus

Interviews Workshops

Act

Evaluate

Process evaluation

Data analysis

Analyse

Leading indicators

Lagging indicators


Leadership

Demonstrated senior

management

commitment and

involvement are vital for

successful health and

safety performance.


Role and responsibilities of leaders

• Stated in regulatory UK legal systems and guidance: – Hazardous Installations Directorate (HID)

Regulatory Model: Safety Management in Major Hazard Industries (2012/13)

– HSG254: Developing process safety indicators: A step-by-step guide for chemical and major hazard industries

• Other: Corporate Governance for Process Safety: Organisation for Economic Co-operation & Development (OECD) guidance for Senior Leaders in High Hazard Industries.


Motivating and

developing

individuals

Upholding group

unity

Manage group

task to achieve

progress and

results

Leadership four dimensions

Shared purpose

Scouller, 2011

Too often most of the effort is on this


Leadership styles

• Why is it important?

•Transformational (lead to worker participation)

•Transactional (lead to worker compliance)

•Other theories:

•Authentic; Resonant; Servant leadership


Transformational leadership defined

• Idealised influence: articulate a vision; act as role models; inspiring trust and respect

• Intellectual stimulation: challenge assumptions and traditional ways of doing things, invite new ideas

• Inspirational motivation: articulate a clear vision that people can aspire to and seek to attain

• Individualised consideration: attention to people needs and development; create a supportive climate promoting learning opportunities

(Bass and Avolio, 1990)


Transactional leadership defined

• Contingent reward: Leader agrees with workers the tasks to be completed and clearly articulates performance expectations in exchange for rewards

• Management by exception – active: actively monitor people behaviour to ensure it complies with expected standards of performance and intervene before problems arise

• Management by exception – passive: intervene only after problems have occurred.

Different from Laissez-faire leadership: Complete avoidance of responsibilities whereby the leader avoids making decisions, ignores people problems or needs and provides neither feedback nor rewards.

(Bass and Avolio, 1990)


Team leaders safety leadership predicting safety performance

Griffin et al 2013 Safety Science


What did workers report doing ?

Safety participation: I put in extra effort to improve the safety of the workplace

I help my co-workers when they are working under risky or hazardous

conditions

I voluntarily carry out tasks or activities that help improve workplace safety

Safety compliance: I carry out work in a safe manner

I use all necessary safety equipment to do my job

I use the correct safety procedures for carrying out my job

I ensure the highest level of safety when I carry out my job

Griffin et al 2013 Safety Science


What did workers see the leader doing?

Safety inspiring: My team leader…

Places a high personal value on the team’s safety

Inspires team members to support safety at work

Presents a positive vision of safety for the team

Safety monitoring: My team leader…

Is alert to safety behaviour in the team

Scans the environment for unsafe actions by the team

Lets me know if I am working unsafely

Safety learning: My team leader…

Encourages new ways of thinking about safety

Sees unsafe behaviour as an opportunity for learning Griffin et al 2013 Safety Science


The effects of transformational leadership on

employees’ absenteeism in four UK public sector

organisations. Mellor, N. et al., 2009

RR846 Research Report – HSE. (www.hse.gov.uk)

A review of the literature on effective leadership

behaviours for safety. Lekka, C. & Healey, N. 2012

RR952 Research Report – HSE. (www.hse.gov.uk)

HSL research on leadership

http://www.hse.gov.uk/

http://www.hse.gov.uk/


Risk Appetite v Risk Tolerance

• Risk Appetite – the pursuit of risk (taking risks)

• Risk Tolerance – what risk the organisation is able to deal with (exercise control)


Risk

Concepts

“Risk Assessment can be like the captured spy:

if you torture it long enough it will tell you

anything you want to know.”

W.D. Ruckelshaus, 1st Administrator of US EPA, 1984


Risk Management Process


TOR and ALARP

Establish Context

Incr

easi

ng

ind

ivid

ua

l ris

ks a

nd

so

ciet

al c

on

cern

s

Unacceptable region

Tolerable Region (if ALARP)

Broadly acceptable region

Intolerable risk

Broadly acceptable risk

TOR = Tolerability Of Risk ALARP = As Low As Reasonably Practicable


TOR and ALARP

Establish Context

Incr

easi

ng

ind

ivid

ua

l ris

ks a

nd

so

ciet

al c

on

cern

s

Unacceptable region

Tolerable Region (if ALARP)

Broadly acceptable region

Intolerable risk

Broadly acceptable risk

TOR = Tolerability Of Risk ALARP = As Low As Reasonably Practicable

risk = likelihood × consequence


Assessing risk

Establish Context

Like

liho

od

Very High

High

Medium

Low

Very Low

Minimal Appreciable Major Severe Catastrophic

Consequence

risk = likelihood × consequence


Business Risk Dimensions

Establish Context HSL Business risks

Failure to deliver

business as usual Failure to

deliver long term

strategy

Financial

Health and Safety

Legal and Compliance

Reputation

Security


Minor?

Security Reputation Legal and

Compliance Financial

Failure to deliver long

term strategy

Failure to deliver

business as usual

Health and Safety

Assessing TOR

Establish Context

Major?

Severe?

Catastrophic?

Appreciable?

Chance? Likelihood? Frequency?


Assessing risk

Establish Context

Like

liho

od

Very High

High

Medium

Low

Very Low


Consequence


Assessing risk

Establish Context

Like

liho

od

Very High

High

Medium

Low

Very Low


Consequence


Application and governance

Establish Context

Business risks

Risk dimensions

Family A Family B Family C Family D

Family E Family F Family G Family H

Business risk families

Senior managers

Board level

Workforce



Identify Risks

Business risk family A

Business as usual Long term strategy Health and Safety Financial

Legal and Compliance Reputation Security

e.g. Supporting the HSE mission

A

A

A

A


Analysing business risks

Analyse Risks

Supporting the HSE mission

UK business

Worldwide business

Infrastructure & Asset management

Capability

Health and Safety

HSL Risk Families HSL Risk Dimension


Organisational risk evaluation

Evaluate Risks

Like

liho

od

V High

High

Med A

Low

V Low

Min Appr Maj Sevr Cat

Consequence

Like

liho

od

V High

High

Med B

Low

V Low


Consequence

Like

liho

od

V High

High C

Med

Low

V Low


Consequence

Risk Families

A

B

C Li

kelih

oo

d

V High

High C

Med A B

Low

V Low


Consequence

Risk Dimension

Risk Dimension 1: close to ‘intolerable’


Organisational risk evaluation

Evaluate Risks

Like

liho

od

V High

High

Med

Low A

V Low


Consequence

Like

liho

od

V High

High

Med B

Low

V Low


Consequence

Like

liho

od

V High

High

Med C

Low

V Low


Consequence

Risk Families

A

B

C Li

kelih

oo

d

V High

High

Med B C

Low A

V Low


Consequence

Risk Dimension

Risk Dimension 2: ‘broadly acceptable’


Risk management and register

Controlling risks

Business risks

Risk dimensions

Family A Family B Family C Family D

Family E Family F Family G Family H


Senior managers

Board level

Workforce

Risk register

Risk management


ASCENT: Analyse

Focus groups

Interventions

SMART action plans

Intervention impact

evaluation


Project plan

Steering group


Focus


Act

Evaluate

Process evaluation

Data analysis

Analyse

Leading indicators

Lagging indicators


Key Performance Indicators

• Managing process safety requires a systematic approach

• KPIs can help measure process safety (and other) performance, aid decision making, and thus proactively prevent problems from occurring

• How KPIs change with time can provide more sophisticated management information by helping you anticipate the future


Key Performance Indicators (continued)

• Provides senior management, the regulator and the public with assurance of industry’s safety performance and management

• Provide an early warning that critical safeguards have deteriorated or will deteriorate so timely actions/decisions can be taken to drive change

• Enable planning of resources

• Enable benchmarking, both within and between comparable sites


Key Performance Indicators (continued)

• Reactive Lagging Indicators – recording consequences • Loss of containment incident rate • Vessel/pipe degradation % metal loss • Numbers of high level alarms activated

• Proactive Leading Indicators – strength of barriers • Safety training percent complete • Isolations completed to required standard • % of alarm systems inspected/maintained to schedule

• KPIs often split into: • People • Process • Plant Integrity

• KPIs needed for different management levels


Guidance – lots!!!


Reason’s “Swiss cheese” model of accident causation

Some holes due

to active failures

Other holes due to

latent conditions

Hazards

Losses


Six steps to KPIs: HSG 254

STEP 1:

Establish KPI team

and support

STEP 2:

Decide what can go

wrong and where

STEP 3:

Set lagging indicators

STEP 4:

Set leading indicators

STEP 5:

Establish data collecting

and reporting system

STEP 6:

Use – and Review!


What we have learnt since HSG 254 was first published in 2005?

• Major accidents continue to occur

• Inquiries repeatedly point to failings in Process Safety Management and Leadership that could have been detected by an effective KPI programme

• The case for having KPIs has never been clearer or stronger

• But, many organisations are still having difficulty in implementing KPIs


So what’s the problem?

• Poor understanding of factors that need to be taken into account when establishing a KPI programme

• Absence of effective leadership to drive forward a KPI programme

• Over emphasis on the difference between leading & lagging indicators to the detriment of acting on information


So what’s the problem?

• Seeking a quick solution or simplistic measure of major hazard risk

• A need for a better understanding of the difference between Sector Indicators and site-based indicators

• An over focus on benchmarking

• Demand for absolute proof that KPIs reduce the risk of a major accident


Factors to take into account

• Engagement with the workforce

• The need for everyone to understand and agree on the ‘risks’,

• How negative results will be treated

• The accuracy with which the KPI reflects the condition and status of a control measure

• How easily and reliably data can be captured


The Importance of Leadership

• Persuade me vs I insist

• Most senior executives need to be strongly persuaded why a KPI programme is needed rather than expecting or demanding that such a programme is implemented


Sector vs Site-specific KPIs

• No ‘one size fits all’ solution

• KPIs need to be tailored to the risks present at each facility or installation

• Generic indicators will be less focused

• Sector-based indicators can realistically only succeed where they reflect the main risks present in all operations

• Benchmarking is useful but not the main aim of a KPI programme


Leading vs Lagging

• A leading indicator can never be an incident or a near miss – that’s just good fortune

• The difference is not that important

• Information to act upon is key!


Are Indicators Predictive of a Major Accident?

• Only where KPIs have been set to measure the control system barrier that is designed to prevent the accident

• You can’t measure what you don’t have

• Deterioration or breakdown of systems will lead to a major accident whether you measure system status or not


Essential Characteristics of KPIs

• Reflect the consensus of the risk profile of the organisation/ activity

• Tailored to the specific risks

• Focus on vulnerability and provide opportunity for early intervention

• Based on data already available

• What they measure and why the issue is important clearly defined


Methodology

• Sketch out the process / activities

• Identify and map onto the process diagram the main challenges to integrity

• Identify what systems and barriers exist to prevent those challenges materialising

• Select the most important in terms of criticality and vulnerability


Safety Critical

System Vulnerable to failure


Is the control measure critical?

• Relates to controlling process conditions?

– Temperature, pressure, flow, level, corrosion?

• Does it lie on the critical path to a major accident? MA initiator should it fail?


Is the system Vulnerable? Key words

• Last in line?

• Provides no warning of failure?

• Offers little or no opportunity of recovery?

• Relies heavily on human intervention or correct action?


KPIs – a systems based method

‘Developing System-Based Leading Indicators for Proactive Risk Management in the Chemical

Process Industry’

Ibrahim A. Khawaji

Massachusetts Institute of Technology

June 2012



GOALS

• Are the safety constraints comprehensive? i.e. covering all the hazards

• Are safety constraints adequate? i.e. using the appropriate controls

• Are safety constraints functional? i.e. ensuring they are implemented and not degraded

• Are safety constraints adaptable?

• i.e. controls address changes in the system



Leading Indicators Development Process

• Detect Flaws (feedback/leading indicators)

• Define factors resulting in the flaws

• Take corrective action to address the factors

• Monitor progress and effectiveness of the process (feedback/leading indicators)


ASCENT: Focus

Focus groups

Interventions

SMART action plans

Intervention impact

evaluation


Project plan

Steering group


Focus


Act

Evaluate

Process evaluation

Data analysis

Analyse

Leading indicators

Lagging indicators


Safety culture excellence assessment

Focus groups & interviews

Leading & lagging

indicators

SMS & documentation

review


Safety culture excellence levels


1. What do you have in place in your own organisation that reflects mindful organising principles ?

2. What could be improved?

– Use of diagnosis questionnaires

The infrastructure of mindful organising


ASCENT: Act

Focus groups

Interventions

SMART action plans

Intervention impact

evaluation


Project plan

Steering group


Focus


Act

Evaluate

Process evaluation

Data analysis

Analyse

Leading indicators

Lagging indicators


How to manage mindfully

1. Small wins in the preoccupation with failure

• Define near miss: system’s safeguard or vulnerability?

• Clarify what constitute ‘good news’

• Create awareness of vulnerability



2. Small wins in resistance to simplification

• Raise doubts to get information

• Handling disagreement or conflicting views

• Treat all unexpected events as information

3. Small wins in sensitivity to operations

• Encourage people to speak up

• Develop sceptics

• Brief people meaningfully



4. Small wins in commitment to resilience

• Treat your past experience with ambivalence

• Accelerate feedback

• Develop competencies

5. Small wins in deference to expertise

• Create flexible decision structures

• Boost imagination for managing the unexpected

• Enhance experts self-awareness


Visible Leadership

• Get out and about often enough and at the right time

• Asking the right questions about the right things in the right way

• Find why they are doing it rather than just who’s doing it.


Setting an Example (Modelling)


Challenging Unsafe Behaviour

• Challenging is an act of caring

• You see dangers they may not

• If someone challenges you

thank them!

E:/Videos/kitchen_high_talker.wmv


Discretionary Effort

“Want to Do it”

Minimal Compliance

“Have to Do it”

Reinforcement

Punishment

4 : 1

Recognition


‘Leadership For Safety’- Fleming, 2001

Looked at the practices of 23 offshore supervisors that were rated as

‘effective’ and ‘ineffective’ by their subordinates:

Effective supervisors:

Valued subordinates more

Visited the worksite more often to check if subordinates needed assistance

Encouraged participation in decision making

Ineffective supervisors:

Abdicated responsibility for subordinate safety

Focussed more on productivity and deadlines

Felt under pressure to get the job done, often at the expense of safety


Risk Awareness techniques

• Step back five by five

• Mining – SLAM & SMART

• Air force ‘three ways’

• Risk triggered commentary


Miners: SLAM

• Stop Think through the task

• Look Identify the hazards for each job step

• Analyze Determine if you have the proper knowledge, training, and tools

• Manage Remove or control hazards and use proper equipment


Mine Operators: SMART

• Stop Isolate each step in a task and identify past and potential accidents, injuries, and violations.

• Measure Evaluate the risks associated with the task and barriers that have allowed hazards to cause injuries

• Act Implement controls to minimize or eliminate any hazards that make the risk unacceptable

• Review Conduct frequent work site visits to observe work practices and audit accidents, injuries, and violations to identify root causes

• Train Develop a human factor-based action plan and then involve and train the miners


• Esso

“Step back five by five” program

Take five minutes to think about what might go wrong and how this might be avoided.

• Air Force pilots

Risk assessments prior to sorties. Identify three ways in which things might go wrong and steps which will be taken to ensure that these unwanted outcomes do not occur.

(Hopkins, 2002)


Risk Triggered Commentary

Source: Rail Safety & Standards Board


Risk Triggered Commentary

• RTC technique: Risk Triggered Commentary - Think it through. RTC involves the person speaking aloud what they usually just think to themselves, when performing an action (driving, signalling, etc).

• RTC allows the person to “sense check” what they should do next.

• It is not just repeating what they see (e.g. The train is

arriving at a junction), but saying the required action they will need to take. E.g. “next signal is a single yellow – brake to notch two, once I pass under the bridge”.

Source: Rail Safety & Standards Board


© Crown Copyright 2014

HSL ‘Make it Happen’ model for culture and behaviour change

Interactive influences of organisation, job and

individual characteristics on H&S behaviour


Influences on Behaviour (Physical context)

Organisation

Policies/procedures (e.g. usability, practicality)

Safety Management Systems

Resources (staff, equipment, training)

Health surveillance scheme, etc.

Job

Job design/environment (e.g. staff movements, crowded, confined space, shift patterns, workload, etc)

Control measure provision (e.g. availability, accessibility, maintenance)

Competence/Training


Influences on Behaviour (Social context)

Job/Organisation Committed & Supportive Leadership

Safety culture (just, flexible, reporting,

learning)

Vision and value for safety

Supervisor role

Worker involvement/Autonomy

Team cooperation/support

Open communication

Change management

Extra-organisational influences Foresight systems to consider

emerging hazards, new regulations, etc.


Influences on Behaviour (Individual)

Motivation/Decision Making

Automatic:

Cognitive/perceptual bias

Skills automaticity/Habits

Reflective:

Knowledge-based

Subjective norms (expectations of

others)

Self-efficacy (confidence in skills)

Beliefs about consequences of

performing behaviour (+/-)

Intention; goals

Mindfulness


Influences on Behaviour/ OSH performance (Individual)

Capability

Knowledge: Information/Update

Education/Training/Refresher

Knowledge sharing

Skills:

Intra & interpersonal skills

(Assertiveness, Situation awareness, Leadership, Decision-making, Teamwork, Resilience in emergency procedures, etc.)


ASCENT: Evaluate

Focus groups

Interventions

SMART action plans

Intervention impact

evaluation


Project plan

Data analysis

Steering group


Analyse

Focus

Interviews

Leading indicators

Workshops

Act

Evaluate

Process evaluation

Lagging indicators


The 5 Whys? - 1

There is a puddle of oil on the shop floor

Mindless response might be: someone to clean it up and this is just a housekeeping issue.

• We need to ask: why there was a puddle of oil on the floor?

• Because the machine was leaking oil.


The 5 Whys? - 2

• Why was it leaking oil?

• Because the gasket has deteriorated


The 5 Whys? - 3

• Why ?

• Because we bought gaskets of inferior material


The 5 Whys? - 4

• Why?

• Because we got a good deal (price) on those gaskets


The 5 Whys? - 5

• Why?

• Because the purchasing agent gets evaluated on short term cost savings.

In this company, the remuneration/financial policy is leading to cut cost on quality and safety.



TEETH CLEANING

Setting Key Performance Indicators – a quick reminder


Teeth cleaning procedure

• Duration: at least two minutes - 30 seconds brushing each section of your mouth (upper right, upper left, lower right and lower left).

• Frequency: morning and night.

• Technique: – Start with outer and inner surfaces, brush at a 45-

degree angle in short, half-tooth-wide strokes against the gum line. Make sure you reach your back teeth.

– Once you get to the inside surfaces of your front teeth, tilt the brush vertically and use gentle up-and-down strokes with the tip of brush.

– Move on to chewing surfaces. Hold the brush flat and brush back and forth along these surfaces.

Source: Oral-B Institute (other toothbrush brands are available)


Teeth cleaning equipment

• Teeth

• Toothbrush

• Toothpaste

• Timer?


Teeth cleaning outcomes

• What is the desired outcome from the teeth cleaning process?

• Can the outcome be readily detected?

• Can the outcome be measured?


Teeth cleaning outcomes

• Its very important to select indicators that, in the main, directly show how well the systems are working in practice, i.e. those linked to process controls.

No tooth decay

No fillings Wet toothbrush

Toothpaste used up Fresh breath

Clean teeth

Time spent in the bathroom


Teeth cleaning KPI (Lagging)

• Lagging indicator – number or percentage of times that teeth are clean when checked (need to agree a performance standard)

IMPORTANT: If teeth aren’t clean we need to investigate to understand why


Teeth cleaning KPI (Leading)

• Leading indicators

– the number of times that critical equipment (toothbrush etc.) is available and in the right condition

– when checked, the percentage of times the correct teeth cleaning process is followed

IMPORTANT: Checking the procedures are being followed is more useful than checking standard operating procedures are in place.

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